Healthcare Provider Details

I. General information

NPI: 1790076370
Provider Name (Legal Business Name): 139 MEDICAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2011
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 CENTRE ST SUITE 618
NEW YORK NY
10013-4552
US

IV. Provider business mailing address

139 CENTRE ST SUITE 618
NEW YORK NY
10013-4552
US

V. Phone/Fax

Practice location:
  • Phone: 212-925-4993
  • Fax: 212-925-4665
Mailing address:
  • Phone: 212-925-4993
  • Fax: 212-925-4665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number214391
License Number StateNY

VIII. Authorized Official

Name: DR. KA LI
Title or Position: MEDICAL PROVIDER
Credential: M.D.
Phone: 212-925-4993